NCLEX 10000 Integumentary Disorders Exam Questions with 100% Correct Answers
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Course
Burns
Institution
Burns
When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?
a) Complaints of intense thirst
b) Moderate to severe pain
c) Hoarseness of the voice
d) Urine output of 70 ml the first hour - Answer-Hoarseness of the voice
Cor...
NCLEX 10000 Integumentary Disorders
Exam Questions with 100% Correct
Answers
When assessing a client with partial-thickness burns over 60% of the body, which
finding should the nurse report immediately?
a) Complaints of intense thirst
b) Moderate to severe pain
c) Hoarseness of the voice
d) Urine output of 70 ml the first hour - Answer-Hoarseness of the voice
Correct
Explanation:
Hoarseness is indicative of injury to the respiratory system and could indicate the need
for immediate intubation
What is the primary goal of nursing care during the emergent phase after a burn injury?
a) Promote wound healing.
b) Replace lost fluids.
c) Control pain.
d) Prevent infection. - Answer-Replace lost fluids.
Correct
Explanation:
During the emergent phase of burn care, one of the most significant problems is
hypovolemic shock. The development of hypovolemic shock can lead to impaired blood
flow through the heart and kidneys, resulting in decreased cardiac output and renal
ischemia. Efforts are directed toward replacing lost fluids and preventing hypovolemic
shock.
The nurse is evaluating the client's risk for having a pressure sore. Which is the best
indicator of risk for the client's developing a pressure sore?
a) nutritional status
b) orientation status
c) circulatory status
d) mobility status - Answer-mobility status
Correct
Explanation:
The client's mobility status is the best indicator of risk for development of a pressure
sore.
,A child is brought to the emergency department with a full-thickness burn involving the
epidermis, dermis, and underlying subcutaneous tissue, but does not report pain at this
time. Which of the following statements by the nurse are correct about this type of burn?
Select all that apply.
a) This is a severe burn and nerve endings have been destroyed.
b) Rehabilitation and skin grafting will be necessary.
c) Pain medication has been administered orally and was effective.
d) This is a superficial burn, so no pain is present.
e) The child must be monitored for signs of fluid shift - Answer-• This is a severe burn
and nerve endings have been destroyed.
• The child must be monitored for signs of fluid shift.
• Rehabilitation and skin grafting will be necessary.
Correct
Explanation:
This is an example of a third-degree burn, which is very serious. This child must be
carefully monitored for complications. The fact that there is no pain is due to the
destruction of the nerve endings. Fluid shift can occur and result in shock. A burn of this
degree will also require a long rehabilitation with skin grafting.
A client is recovering from an infected abdominal wound. Which foods should the nurse
encourage the client to eat to support wound healing and recovery from the infection?
a) cheeseburger and french fries
b) cheese omelet and bacon
c) gelatin salad and tea
d) chicken and orange slices - Answer-chicken and orange slices
Correct
Explanation:
Protein and vitamin C are particularly important in promoting wound healing and
recovery from infection. A diet high in carbohydrates is also essential. Because the
client with an infection commonly does not feel like eating, it is important that what the
client eats should be nutritious. Chicken and orange slices would help meet the client's
protein and vitamin needs.
In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness
burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which
finding shows that the fluid resuscitation is benefiting the client?
a) A urine output consistently above 40 ml/hour (40 mL/hour)
b) Body temperature readings all within normal limits
c) A weight gain of 4 lb (2 kg) in 24 hours
d) An electrocardiogram (ECG) showing no arrhythmias - Answer-A urine output
consistently above 40 ml/hour (40 mL/hour)
Correct
Explanation:
, In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood
pressure that provides adequate perfusion of vital structures. If the kidneys are
adequately perfused, they will produce an acceptable urine output of at least 0.5
ml/kg/hour. Thus, the expected urine output of a 155-lb (70 kg) client is 35 ml/hour, and
a urine output consistently above 40 ml/hour is adequate. Weight gain from fluid
resuscitation isn't a goal. In fact, a 4-lb (2 kg) weight gain in 24 hours suggests third
spacing.
The nurse is caring for a client who has severe burns on the head, neck, trunk, and
groin areas. Which position would be most appropriate for preventing contractures?
a) semi-Fowler's
b) high Fowler's
c) supine
d) prone - Answer-supine
Correct
Explanation:
Supine in extension is the position most likely to prevent contractures. Clients who have
experienced burns will find a flexed position most comfortable. However, flexion
promotes the development of contractures.
A client comes to the physician's office for treatment of severe sunburn. The nurse
takes this opportunity to discuss the importance of protecting the skin from the sun's
damaging rays. Which instruction best prevents skin damage?
a) "Apply sunscreen even on overcast days."
b) "Use a sunscreen with a sun protection factor of 6 or higher."
c) "When at the beach, sit in the shade to prevent sunburn."
d) "Minimize sun exposure from 1 to 4 p.m., when the sun is strongest." -
Answer-"Apply sunscreen even on overcast days."
Correct
Explanation:
Sunscreen should be applied even on overcast days, because the sun's rays are as
damaging then as on sunny days.
Which of the following would provide the most effective emergency care for a burn
victim at the accident site?
a) Pouring cool water over the burned area.
b) Applying clean, dry dressings to the area.
c) Applying a mild antiseptic ointment to the area.
d) Rinsing the area with a warm, mild soap solution. - Answer-Applying clean, dry
dressings to the area.
Incorrect
Correct response: Pouring cool water over the burned area.
Explanation:
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